Basic Information
| Provider Information | |||||||||
| NPI: | 1982081543 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ALKHAWALDEH | ||||||||
| FirstName: | LARA | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3127703270 | ||||||||
| Practice Location | |||||||||
| Address1: | 1127 N OAKLEY BLVD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606223507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127702040 | ||||||||
| FaxNumber: | 3127703270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2015 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01079976A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 125067573 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | 036144150 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 300021101 | 05 | IN | MEDICAID |